Get Authorization To Disclose Protected Health ... - State Of Michigan - Michigan

This guide provides clear and practical instructions on filling out the Authorization To Disclose Protected Health Information form for the State of Michigan. This authorization is essential for sharing medical records, ensuring that the necessary information is sent to the relevant health care providers.

Follow the steps to complete your authorization form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the patient’s name, date of birth, and their address. Ensure all details are accurate to avoid any delays.
3. Enter the CSHCS/Medicaid ID number along with the city, state, and ZIP code where the patient resides.
4. Provide the parent or guardian’s name and phone number. If their address differs from the patient's, include that information as well.
5. In the section for the specialty doctor, hospital, or clinic, write the name and complete address of the healthcare provider who will disclose the records.
6. Authorize the release of the most current medical information by checking the appropriate sections that specify what types of information may be disclosed.
7. Read through the authorization statements carefully. Sign and date the authorization at the bottom as the patient, parent, or legal guardian.
8. Have an adult witness sign and date the authorization form. This step is crucial for validating the document.
9. Once completed, retain the pink copy for personal records, send the white copy to the healthcare provider, and attach the yellow copy with the recent medical information to be mailed to the Michigan Department of Community Health.
10. Finally, save your changes, and if needed, download, print, or share the completed form as required.

Complete your documents online today to ensure timely processing and proper care.